Percutaneous Revascularization of Chronic Total Coronary Occlusion
2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 6 Linguagem: Inglês
10.1161/circinterventions.117.005512
ISSN1941-7632
AutoresAndrew Kei‐Yan Ng, Pinak Shah, David O. Williams,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculation: Cardiovascular InterventionsVol. 10, No. 6Percutaneous Revascularization of Chronic Total Coronary Occlusion Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessArticle CommentaryPDF/EPUBPercutaneous Revascularization of Chronic Total Coronary OcclusionFor Whom? Andrew Kei-Yan Ng, MD, Pinak Bipin Shah, MD and David O. Williams, MD Andrew Kei-Yan NgAndrew Kei-Yan Ng From the Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. , Pinak Bipin ShahPinak Bipin Shah From the Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. and David O. WilliamsDavid O. Williams From the Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Originally published14 Jun 2017https://doi.org/10.1161/CIRCINTERVENTIONS.117.005512Circulation: Cardiovascular Interventions. 2017;10:e005512Although chronic total occlusion (CTO) of a coronary artery is a common finding,1 there is little consensus as to whether such lesions should be treated routinely by percutaneous coronary intervention (PCI). Benefits of successful CTO PCI include relief of symptoms, resolution of ischemia, improvement in left ventricular function, and avoidance of coronary bypass surgery.2 Conversely, unsuccessful CTO PCI is common, and there are several potential adverse consequences associated with attempting PCI of a CTO. Early in the learning curve, procedures tend to be longer with increased contrast and radiation exposure to the patient.3,4 Coronary perforation is also more frequent with CTO attempts than non-CTO lesions and may be associated with cardiac tamponade, need for emergency surgery, and death.5 Rates of successful CTO are variable and highly dependent on operator skill and experience. Traditional technical success rates range between 60% and 75%,2,6 much lower than rates for non-CTO lesions. In the current era, however, with contemporary techniques and with operators with expertise in CTO PCI, success rates of 80% to 90% have been achieved.5,7Lack of success can be attributed to procedural challenges that are specific to CTO, and accordingly, approaches unique to coronary CTO PCI have been developed. The major barrier is the inability to traverse the occluded segment with a guidewire because the composition of a CTO includes fibrotic, calcified tissue with no well-defined lumen.CTO PCI requires different equipment compared with standard PCI. Large lumen guide catheters together with extra long sheaths are essential to provide sufficient backup support.8 A unique aspect of CTO PCI is the intentional use the extraluminal space of the obstructed coronary artery to gain access to the coronary lumen beyond the occlusion,9,10 known as the antegrade dissection and reentry technique. Specially designed hydrophilic guidewires supported by a microcatheter can be intentionally directed antegrade through the subintimal region. Reentry may then be facilitated by specially designed catheters that direct guidewires back into the true lumen of the vessel.11 Loss of side branches is a potential complication of this technique.The retrograde approach to CTO PCI is more challenging but an essential technique for CTO operators to master to achieve successful recanalization. The lesion is penetrated from the artery distal to the occlusion by using collateral channels to gain access to the lesion.12,13 This approach is enhanced by using specially designed microcatheters that enhance wire and balloon delivery and protect collateral donor arteries (ie, septal perforators) that serve as the conduits to enable retrograde access. CTO crossing may require the reverse controlled antegrade and retrograde subintimal tracking technique where antegrade balloon inflation creates a space within the CTO to enable retrograde wire entry into the proximal true lumen.14With CTO PCI, many of the basic fundamentals of standard PCI are abandoned, for example, avoiding subintimal dissection. Also many of the devices used for CTO PCI are unique to the procedure and are otherwise unfamiliar to the standard PCI operator. Such concerns are likely in part responsible for the significant difference in CTO success rates when comparing outcomes of modest to high-volume operators.4,15,16 Some have suggested an annual volume of 50 CTO cases as a reasonable threshold to maintain high proficiency in CTO PCI for any individual operator.16 Because CTO is present in upwards of 20% of all coronary angiograms and only a portion of those are indicated for revascularization, it will require an annual volume of at least 500 to 600 coronary angiograms to maintain one dedicated CTO interventionist. Therefore, it is critical that CTO PCI be performed in high-volume centers of clinical excellence with the technique. Accordingly, for institutions with lower volumes, it is important to initiate a referral system such that patients who require CTO PCI can be treated appropriately.Given these considerations, are the benefits of achieving successful CTO PCI worth the challenges? Most published studies of CTO PCI are observational. Typically CTO patients who undergo successful PCI are compared with those in whom PCI was unsuccessful. Patients in whom PCI was successful fare better in terms of relief of symptoms17 and subsequent mortality.16,18–20 Unfortunately such observational studies cannot determine whether PCI is superior to medical therapy alone for CTO patients. It is possible that patients who experience CTO PCI success differ from those in whom CTO PCI is unsuccessful. Successfully treated patients may have features that place them at lower risk for subsequent events. For example, in the New York State Registry, successfully treated CTO patients were younger and had higher left ventricular ejection fractions than those in whom PCI failed.16Two randomized clinical trials have assessed the outcomes of CTO PCI. The EXPLORE trial (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) randomized 304 patients who initially presented with ST elevation myocardial infarct and additionally a CTO of the noninfarct artery.21 Patients were randomly assigned to receive CTO PCI or medical therapy after primary PCI. The primary end point of left ventricular ejection fraction at 4 months after the procedure was not significantly different between the 2 strategies. Subgroup analysis showed a potential benefit for intervention in patients with CTO of the left anterior descending. This study was limited by slow enrollment and a relatively low technical success rate of 73%. Importantly this trial was underpowered to detect any benefit in clinical events. A second randomized clinical trial, the DECISION-CTO trial (Optimal Medical Therapy With or Without Stenting for Coronary Chronic Total Occlusion), assigned 834 patients to CTO PCI or medical therapy. Despite a high technical success rate of 91%, there was no difference between the groups in the 3-year composite rates of death, myocardial infarct, stroke, or any repeat revascularization. Critics of this trial cite early termination because of slow enrollment, a 20% crossover rate from medical therapy arm to PCI arm, and question whether the treated CTO was the actually the culprit lesion. Taken together, these trials fall short in justifying routine PCI for all CTO lesions but similarly have not determined which patients may stand to gain the most from this procedure.As in all patients with coronary disease, medical management should be optimized for the CTO patient.22,23 Given the technical challenges of CTO PCI, many have considered that medical management alone is an appropriate therapeutic approach for the CTO patient, especially in the setting of single vessel disease, modest symptoms, and low ischemic burden.24 This strategy is supported by the concept that the threat of myocardial infarction is minimal given that coronary occlusion has already occurred and viability is maintained by the coronary collateral circulation.Another concern is that CTO PCI can challenge hospital resources, usually consuming greater laboratory time and procedural devices. On the contrary, one publication concludes that these procedures produce a financial contribution margin to the hospital similar to that of non-CTO PCI.25 Performing CTO intervention may also bring advantages of reputation, referrals, clinical trials of new devices, and investigational treatments.We suggest the following recommendations for the performance of CTO PCI. First, CTO PCI should only be performed in high-volume PCI centers with on-site cardiac surgical backup. Second, performance of CTO PCI should be performed by experienced operators, ideally ≤2 operators who can work together, whose main clinical focus in the catheterization laboratory is CTO PCI. Patients selected for CTO PCI should have a documented ischemic burden and significant anginal symptoms, despite optimization of medical therapy. These are the patients who stand to gain the most in terms of improvement in quality of life.22,26–28 Whether CTO PCI should be performed for ischemia without symptoms has yet to be determined. The nuclear substudy of the COURAGE trial (the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) suggested a mortality benefit of revascularization when the ischemic burden involved ≥10% of myocardial muscle mass. The results of the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) may help provide clarity to this finding. Finally, CTO PCI offers opportunities for the development of better devices to enhance procedural ease and safety. It is anticipated that the device industry will continue to develop and evaluate new products focused on enhancing CTO PCI.AcknowledgmentsThe authors wish to acknowledge the programmatic contributions of Kevin Croce, MD, PhD.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to David O. Williams, MD, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. E-mail [email protected]References1. Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M, Bierstone D, Sparkes JD, Wright GA, Strauss BH. Current perspectives on coronary chronic total occlusions: the Canadian multicenter chronic total occlusions registry.J Am Coll Cardiol. 2012; 59:991–997. doi: 10.1016/j.jacc.2011.12.007.CrossrefMedlineGoogle Scholar2. Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis.Am Heart J. 2010; 160:179–187. doi: 10.1016/j.ahj.2010.04.015.CrossrefMedlineGoogle Scholar3. Patel VG, Brayton KM, Tamayo A, Mogabgab O, Michael TT, Lo N, Alomar M, Shorrock D, Cipher D, Abdullah S, Banerjee S,, Brilakis ES. Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions: a weighted meta-analysis of 18,061 patients from 65 studies.JACC Cardiovasc Interv. 2013; 6:128–136. doi: 10.1016/j.jcin.2012.10.011.CrossrefMedlineGoogle Scholar4. Brilakis ES, Banerjee S, Karmpaliotis D, Lombardi WL, Tsai TT, Shunk KA, Kennedy KF, Spertus JA, Holmes DR, Grantham JA. Procedural outcomes of chronic total occlusion percutaneous coronary intervention: a report from the NCDR (National Cardiovascular Data Registry).JACC Cardiovasc Interv. 2015; 8:245–253. doi: 10.1016/j.jcin.2014.08.014.CrossrefMedlineGoogle Scholar5. Morino Y, Kimura T, Hayashi Y, Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata Y, Hiasa Y, Doi O, Yamashita T, Morimoto T, Abe M, Hinohara T, Mitsudo K; J-CTO Registry Investigators. In-hospital outcomes of contemporary percutaneous coronary intervention in patients with chronic total occlusion insights from the J-CTO registry (Multicenter CTO Registry in Japan).JACC Cardiovasc Interv. 2010; 3:143–151. doi: 10.1016/j.jcin.2009.10.029.CrossrefMedlineGoogle Scholar6. Mehran R, Claessen BE, Godino C, Dangas GD, Obunai K, Kanwal S, Carlino M, Henriques JP, Di Mario C, Kim YH, Park SJ, Stone GW, Leon MB, Moses JW, Colombo A; Multinational Chronic Total Occlusion Registry. Long-term outcome of percutaneous coronary intervention for chronic total occlusions.JACC Cardiovasc Interv. 2011; 4:952–961. doi: 10.1016/j.jcin.2011.03.021.CrossrefMedlineGoogle Scholar7. Galassi AR, Tomasello SD, Reifart N, Werner GS, Sianos G, Bonnier H, Sievert H, Ehladad S, Bufe A, Shofer J, Gershlick A, Hildick-Smith D, Escaned J, Erglis A, Sheiban I, Thuesen L, Serra A, Christiansen E, Buettner A, Costanzo L, Barrano G, Di Mario C. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry.EuroIntervention. 2011; 7:472–479. doi: 10.4244/EIJV7I4A77.CrossrefMedlineGoogle Scholar8. Di Mario C, Ramasami N. Techniques to enhance guide catheter support.Catheter Cardiovasc Interv. 2008; 72:505–512. doi: 10.1002/ccd.21670.CrossrefMedlineGoogle Scholar9. Mitsudo K, Yamashita T, Asakura Y, Muramatsu T, Doi O, Shibata Y, Morino Y. Recanalization strategy for chronic total occlusions with tapered and stiff-tip guidewire. The results of CTO new technique for standard procedure (CONQUEST) trial.J Invasive Cardiol. 2008; 20:571–577.MedlineGoogle Scholar10. Colombo A, Mikhail GW, Michev I, Iakovou I, Airoldi F, Chieffo A, Rogacka R, Carlino M, Montorfano M, Sangiorgi GM, Corvaja N,, Stankovic G. Treating chronic total occlusions using subintimal tracking and reentry: the STAR technique.Catheter Cardiovasc Interv. 2005; 64:407–411; discussion 412.CrossrefMedlineGoogle Scholar11. Werner GS. The BridgePoint devices to facilitate recanalization of chronic total coronary occlusions through controlled subintimal reentry.Expert Rev Med Devices. 2011; 8:23–29. doi: 10.1586/erd.10.76.CrossrefMedlineGoogle Scholar12. Brilakis ES, Grantham JA, Thompson CA, DeMartini TJ, Prasad A, Sandhu GS, Banerjee S, Lombardi WL. The retrograde approach to coronary artery chronic total occlusions: a practical approach.Catheter Cardiovasc Interv. 2012; 79:3–19. doi: 10.1002/ccd.23004.CrossrefMedlineGoogle Scholar13. Joyal D, Thompson CA, Grantham JA, Buller CE, Rinfret S. The retrograde technique for recanalization of chronic total occlusions: a step-by-step approach.JACC Cardiovasc Interv. 2012; 5:1–11. doi: 10.1016/j.jcin.2011.10.011.CrossrefMedlineGoogle Scholar14. Tsuchikane E, Katoh O, Kimura M, Nasu K, Kinoshita Y, Suzuki T. The first clinical experience with a novel catheter for collateral channel tracking in retrograde approach for chronic coronary total occlusions.JACC Cardiovasc Interv. 2010; 3:165–171. doi: 10.1016/j.jcin.2009.10.026.CrossrefMedlineGoogle Scholar15. Habara M, Tsuchikane E, Muramatsu T, Kashima Y, Okamura A, Mutoh M, Yamane M, Oida A, Oikawa Y, Hasegawa K; Retrograde Summit Investigators. Comparison of percutaneous coronary intervention for chronic total occlusion outcome according to operator experience from the Japanese retrograde summit registry.Catheter Cardiovasc Interv. 2016; 87:1027–1035. doi: 10.1002/ccd.26354.CrossrefMedlineGoogle Scholar16. Hannan EL, Zhong Y, Jacobs AK, Stamato NJ, Berger PB, Walford G, Sharma S, Venditti FJ, King SB. Patients with chronic total occlusions undergoing percutaneous coronary interventions: characteristics, success, and outcomes.Circ Cardiovasc Interv. 2016; 9:e003586. doi: 10.1161/CIRCINTERVENTIONS.116.003586.LinkGoogle Scholar17. Borgia F, Viceconte N, Ali O, Stuart-Buttle C, Saraswathyamma A, Parisi R, Mirabella F, Dimopoulos K, Di , Mario C. Improved cardiac survival, freedom from MACE and angina-related quality of life after successful percutaneous recanalization of coronary artery chronic total occlusions.Int J Cardiol. 2012; 161:31–38. doi: 10.1016/j.ijcard.2011.04.023.CrossrefMedlineGoogle Scholar18. Hoebers LP, Claessen BE, Elias J, Dangas GD, Mehran R, Henriques JP. Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome.Int J Cardiol. 2015; 187:90–96. doi: 10.1016/j.ijcard.2015.03.164.CrossrefMedlineGoogle Scholar19. Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani DJ, Vo M, Luna M, Alaswad K, Karmpaliotis D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions.Am J Cardiol. 2015; 115:1367–1375. doi: 10.1016/j.amjcard.2015.02.038.CrossrefMedlineGoogle Scholar20. Khan MF, Wendel CS, Thai HM, Movahed MR. Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion.Catheter Cardiovasc Interv. 2013; 82:95–107. doi: 10.1002/ccd.24863.CrossrefMedlineGoogle Scholar21. Henriques JP, Hoebers LP, Råmunddal T, Laanmets P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss BH, Barbato E, Nijveldt R, van Rossum AC, Marques KM, Elias J, van Dongen IM, Claessen BE, Tijssen JG, van der Schaaf RJ; EXPLORE Trial Investigators. Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: the EXPLORE trial.J Am Coll Cardiol. 2016; 68:1622–1632. doi: 10.1016/j.jacc.2016.07.744.CrossrefMedlineGoogle Scholar22. Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O'Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE; COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial nuclear substudy.Circulation. 2008; 117:1283–1291. doi: 10.1161/CIRCULATIONAHA.107.743963.LinkGoogle Scholar23. Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TL, Molitch ME, Nesto RW, Sako EY, Sobel BE; BARI 2D Study Group.A randomized trial of therapies for type 2 diabetes and coronary artery disease.NEngl J Med. 2009; 360:2503–2515. doi: 10.1056/NEJMoa0805796.CrossrefMedlineGoogle Scholar24. Stone GW, Reifart NJ, Moussa I, Hoye A, Cox DA, Colombo A, Baim DS, Teirstein PS, Strauss BH, Selmon M, Mintz GS, Katoh O, Mitsudo K, Suzuki T, Tamai H, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Moses JW, Leon MB, Serruys PW. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II.Circulation. 2005; 112:2530–2537. doi: 10.1161/CIRCULATIONAHA.105.583716.LinkGoogle Scholar25. Karmpaliotis D, Lembo N, Kalynych A, Carlson H, Lombardi WL, Anderson CN, Rinehart S, Kirkland B, Shemwell KC, Kandzari DE. Development of a high-volume, multiple-operator program for percutaneous chronic total coronary occlusion revascularization: procedural, clinical, and cost-utilization outcomes.Catheter Cardiovasc Interv. 2013; 82:1–8. doi: 10.1002/ccd.24387.CrossrefMedlineGoogle Scholar26. Windecker S, Stortecky S,, Stefanini GG, da Costa BR, Rutjes AW, Di Nisio M, Silletta MG, Maione A, Alfonso F, Clemmensen PM, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head S, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter D, Schauerte P, Sousa , Uva M, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A, Kolh P, Juni P. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis.BMJ. 2014; 348:g3859. doi: 10.1136/bmj.g3859.CrossrefMedlineGoogle Scholar27. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, Jagic N, Möbius-Winkler S, Mobius-Winckler S, Rioufol G, Witt N, Kala P, MacCarthy P, Engström T, Oldroyd KG, Mavromatis K, Manoharan G, Verlee P, Frobert O, Curzen N, Johnson JB, Jüni P, Fearon WF; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease.N Engl J Med. 2012; 367:991–1001. doi: 10.1056/NEJMoa1205361.CrossrefMedlineGoogle Scholar28. Erne P, Schoenenberger AW, Burckhardt D, Zuber M, Kiowski W, Buser PT, Dubach P, Resink TJ, Pfisterer M. Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial.JAMA. 2007; 297:1985–1991. doi: 10.1001/jama.297.18.1985.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Innocentiis C, Zimarino M and Caterina R (2017) Is Complete Revascularisation Mandated for all Patients with Multivessel Coronary Artery Disease?, Interventional Cardiology Review, 10.15420/icr.2017:23:1, 13:01, (45), . June 2017Vol 10, Issue 6 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.117.005512PMID: 28615235 Originally publishedJune 14, 2017 Keywordscoronary occlusioncoronary artery bypasspercutaneous coronaryhumansheartPDF download Advertisement SubjectsRevascularization
Referência(s)